CardioNerds at The Houston Shock Symposium 2023: An Interview With Dr. Dan Burkhoff

This year, the CardioNerds are covering The Houston Shock Symposium 2023, or HSS23. In this interview, CardioNerds Conference Scholars Drs. Tommy Das (Cleveland Clinic), and Katie Vaughan (Israel Deaconess Medical Center) spoke with Dr. Dan Burkhoff, who’ll be presenting the teaching and education in advanced cardiovascular hemodynamics course, or TEACH course, for HSS23 attendees. Dr. Burkhoff spoke in-depth about Harvi, which is an interactive simulation based application developed for teaching and researching many aspects of ventricular mechanics and hemodynamics. See what the CardioNerds and Dr. Burkhoff had to say.

Dr. Tommy Das: Hi, everyone. My name is Tommy Das. I’m a current second year general cardiology fellow at the Cleveland Clinic, and Service Program Director for the CardioNerds Academy, a fellowship in digital medical education.

Dr. Katie Vaughan: And my name is Katie Vaughan, and I’m a chief resident at Beth Israel Deaconess Medical Center, where I will remain for cardiology fellowship next year. And I’m a CardioNerds scholar for my project to create a curriculum to teach trainees all about different mechanical circulatory support devices called Devices in a Dash.

And we are so excited to serve as CardioNerds’ conference scholars for the 2023 Houston Shock Symposium with mentorship from Dr. Andrew Higgins.

Dr. Tommy Das: Prior to the HSS ’23 agenda, we have the pleasure of interviewing Dr. Dan Burkhoff, who’ll be presenting the teaching and education in advanced cardiovascular hemodynamics course, or TEACH course for the conference attendees. Dr. Burkhoff, he needs no introduction, but he’s the director of Heart Failure, Hemodynamics, and Mechanical Circulatory Support Research at the Cardiovascular Research Foundation. Where he has done foundational work in basic, translational, and clinical science regarding ventricular dynamics, and novel pharmacologic, and device therapies for heart failure.

Additionally, Dr. Burkhoff is also the author of Harvi, an interactive simulation based application for teaching and researching many aspects of ventricular mechanics and hemodynamics. Welcome, Dr. Burkhoff.

Dr. Dan Burkhoff: Thanks so much, Tommy and Katie, for having me on.

Dr. Katie Vaughan: Yeah, we’re really excited for this conversation tonight. And to start things off, can you describe to our listeners, what is Harvi? And who is part of the Harvi team? And what inspired you all to create this platform?

Dr. Dan Burkhoff: So Harvi is an interactive simulation of the cardiovascular system. The origins of Harvi actually date back to around 1984 when I was a graduate student at Johns Hopkins. As part of my research, I was learning about cardiovascular physiology and ventricular vascular coupling. And we worked in a lab where these were the fundamental things that we were studying, and also describing ventricular mechanics and arterial ventricular coupling in mathematical terms.

And that then led to the development of simulations. A birth of simulations that are now part of the foundation of our Harvi simulator.

In 1992, I moved to Columbia, and I teamed up with my partner in this endeavor, Marc Dickstein, who’s a professor of anesthesia at Columbia. And we’ve been working literally together for the last 30 years to develop Harvi, both the simulation aspects but also the teaching aspects.

So now, Harvi consists of a simulation. It’s a series of online textbooks, and then there’s also a series of video lectures that people can access. Which include interactive lessons and questions, self-assessment questions. So it’s evolved quite a bit over the last almost 40 years, and it continues to evolve.

Dr. Tommy Das: Oh, thank you so much, Dr. Burkhoff, for that overview. I think there’s so many things that the Harvi platform has and can offer people. And when I was first introduced to it, I think what really captured my attention and interest was the simulator. Just being able to change so many different variables and pull so many levers, and kind of try to replicate a patient scenario. To think in terms of nuts and bolts, could you walk us through how you can use the Harvi simulator to actually model a certain scenario? For especially when some things are changing so dynamically for a challenging sick patient.

Dr. Dan Burkhoff: Sure. That was really a lot of the motivation of developing the Harvi simulator, so that we would be able to simulate clinical scenarios, and also simulate the effects of all kinds of therapeutic interventions.

So first of all, if you can imagine a clinical scenario that involves a hemodynamic aspect, it’s most likely that Harvi can simulate it. Obviously, we have the simulation of the right and the left ventricles, the right and left atria, the pulmonary and systemic vasculature. We have the valve, so you can have all the valve lesions. And as you were referring to, there are controls that allow you to vary. There are dozens and dozens of parameters, and a lot of the textbooks really are geared towards teaching what the different parameters are in a clinically relevant manner.

But when you go through these and get a glimpse of all the different parameters that there are, you kind of get a sense of all the things that really, cardiologists who are interested in hemodynamics, really should know. But really very few do know.

So that’s really where the teaching aspects come in, and also the textbooks and the self-learning lectures. I should emphasize that the interface for Harvi is very graphical. So there’s a graphical interface, so you see pressure volume loops of all the four chambers. You can see pressure over time. You can see volumes over time, ECGs, flows. We have modules that even simulate Doppler flow signals from echo Dopplar. There are all sorts of outputs, including things that mimic a patient monitor.

Anyway, the point is that there are many, many parameters that you can adjust and understand how they impact on cardiovascular performance. In terms of simulating patients, there are really two approaches. One is you could say, “Okay, I want to simulate a particular patient and I’m going to adjust all of the parameters that I think are important, and to try to get to the final hemodynamic profile.” Meaning blood pressures, pulmonary pressures, cardiac outputs, et cetera.

The other way that we have built into Harvi is what we refer to as the patient simulator, where you can input the patient parameters. Like from a right heart cath and plus the ejection fraction, the heart rate, the blood pressure. And then the standard parameters from a right heart cath, and Harvi will then automatically adjust the parameters to simulate your patient. So that gets you there very quickly.

And then once you have that, you can start exploring the effects of different interventions. And for example, if you’re interested in mechanical circulatory support, either acute or a durable support, we’ve got many, many different support devices that are programmed in including balloon pumps. We have about 10 or 11 different configurations of ECMO, including VA and VAV, and all kinds of variations of taking blood from one place to another. We have all of the different Impella devices programmed in, and also left-sided and right-sided support. We have tandem heart, right-sided support and left-sided support, devices programmed.

In addition, we also have the durable VADs, like the HeartMate 3, and we still have the Legacy HVAD devices programmed in. And with regard to those, the durable VADs, you can even see the flow waveforms. And as well as for the Impella devices.

We also use the simulator to teach the fundamentals of mechanical circulatory support. So maybe you’ve heard of the HQ curve of a mechanical support device, which really is the hemodynamic signature of the different pumps. Well, we go through those, what an HQ curve is, which really is telling the pressure flow characteristics of different pumps. And how you understand what the importance of those HQ curves in determining how the heart and vasculature respond to a particular device that’s put in. So that requires learning a little bit about the HQ curve.

So the Harvi simulator’s extremely rich in teaching opportunities, and learning opportunities may be more accurately, of really almost any aspect of hemodynamics.

Dr. Katie Vaughan: Yeah, thank you so much for going through that. It sounds, just as you mentioned, an incredibly rich simulator of so many different levels of things that you can really build on each other. From the basics, thinking about levels of all different trainees that can really benefit from this program and everything that it offers.

Thinking about that education and the learning opportunities that you mentioned, how do you envision using the Harvi simulator in programs like the TEACH course as part of regular education and growth for a cardiovascular fellowship program, and fellows on their career path?

Dr. Dan Burkhoff: Well, I think it’s not a lot of training that fellows get on hemodynamics in most programs. So I think that we do offer something that really fills a void from my opinion. I think anyone who goes into heart failure, or interventional cardiology, or structural, that is going to be dealing with devices and hemodynamic problems, should really have a good working knowledge of the modern concepts of ventricular mechanics and ventricular vascular coupling. And that’s what the environment of Harvi, including the books and the lectures, really provide.

So there is an opportunity for self-learning if people want to take the time to do that. However, if people don’t want to do that, we offer the TEACH course. So TEACH was developed about seven or eight years ago, and the full TEACH course is about seven hours of interactive lectures where we go through the basics of ventricular vascular mechanics. We go through the basics of hemodynamic support, and we go through different scenarios like cardiogenic shock. We talk about high risk PCI and support during high risk PCI. And in regards to that, we talk a lot about the determinants of myocardial oxygen consumption and the physiology of coronary blood flow, which is also a topic in and of itself. So that full course is around seven or eight hours depending on how deeply we go.

We’ve been putting on those longer courses kind of in association with some of the national or international meetings, like the ACC, or ISHLT, or HFSA. We usually do one every year at HFSA. Not the full course, we kind of focus in with HFSA. We do a two to three hour course.

In addition, we do go to individual fellowship programs. So if we’re invited to a fellowship program, we’ll come for a day. And we’ll do a two and a half to three hour course. Mind you, when we do a two and a half hour or three hour course, it’s really just scratching the surface of what there is to learn, and what there is to interact with Harvi on. But nevertheless, it is a good start.

Some programs have me back every year, and I basically do the same course every year. We update it every year as new information comes out, especially about cardiogenic shock. But it turns out that people coming back to the same course and seeing the material a second time, for fellows who are in their first or second year, it’s provided a lot of value. At least that’s the feedback that I get. Because if you’re just passive learning and not really going to take more active learning after these courses, then once through is not enough.

But I think for those that are really committed to MCS, and hemodynamics, and physiology. Spending a lot of time with Harvi, there’s a lot in there between the books and the lectures.

Dr. Tommy Das: Excellent. Thank you, Dr. Burkhoff, for outlining those opportunities. I think from an educational perspective, you just see how this is so important in terms of supplementing the clinical situations and educational opportunities that we’re all exposed to as fellows. But having a platform wherein a learner who is self-directed and motivated and knows their interest, whether they be in mechanical support, critical care, structural interventions. As you say, can really tailor their education further, is so key and so important.

Piggybacking off of that, I think my next question would just be, looking towards the future, what do you envision as the next steps for the Harvi tool? And how do you want to expand the program and the educational initiative going forward?

Dr. Dan Burkhoff: Well, we continue to update and add features to Harvi, and it continues to grow. I should also mention, in addition to the hemodynamic aspects, there is also blood gas physiology there. So especially when you get into lung failure, pulmonary edema, and VA ECMO, VV ECMO, all of those things teaching about the patient interaction with the oxygenation, CO2, and also the ventilators. It’s all in there as well.

So I think that Dr. Dickstein and myself, are really offering ourselves out there to go out and do these programs. It’s really incumbent on the fellows or the program directors to reach out, and we work with dozens of fellowships each year. And each one has a different interest, and it really depends on fellowship program directors or fellows asking for it.

It’s our vision that we would like to see Harvi used in every single medical school, to teach physiology at the medical school level. To introduce it, and also at every single cardiology fellowship program. So that’s our vision.

But to make that a reality, it really takes the desire of the people on the other side of this equation, which are the students and the teachers. But on our part, we try to provide all of the tools that are necessary for these courses to be implemented at either independently at the schools and programs, or with our assistance.

Dr. Katie Vaughan: Yeah. Thank you so much for going through that and what an incredible opportunity to have you coming to the fellowship program, or to the schools and to the programs, would be a really wonderful experience. So I’m glad that you guys are offering your services across the country and beyond, to get that experience and really develop that understanding for the fellows. And even beforehand, starting in the medical school as you mentioned.

So thank you so much for taking the time, Dr. Burkhoff, to speak with us tonight. Really, I learned so much in our discussion and are really, really excited to be one, using Harvi more frequently, and also learning from you in the TEACH course.

And for our audience, be sure to follow the CardioNerds Conference Scholars to keep up with key takeaways from your favorite conferences. And thanks for joining tonight.